Provider Demographics
NPI:1154467694
Name:LUCKETT, JACQUELINE M (OTR-L)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:M
Last Name:LUCKETT
Suffix:
Gender:F
Credentials:OTR-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 BRAMBLETON AVE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3436
Mailing Address - Country:US
Mailing Address - Phone:540-961-1230
Mailing Address - Fax:540-951-0613
Practice Address - Street 1:4515 BRAMBLETON AVE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3436
Practice Address - Country:US
Practice Address - Phone:540-961-1230
Practice Address - Fax:540-951-0613
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA119003189225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7156232OtherAETNA